Radial artery graft use and off-pump coronary artery bypass surgery outcome.

Radial artery is commonly used as a conduit for surgical revascularization. There is scarce data on the effect of radial artery use on outcome following off-pump coronary artery bypass. We prospectively evaluated 591 patients undergoing off-pump coronary artery bypass. Radial artery grafts were used in 398 of these patients (mean age, 67.6 +/- 10.4 years; mean follow-up, 37.7 +/- 13.4 months). Symptom recurrence (angina, congestive heart failure), adverse cardiac events (myocardial infarction, coronary re-intervention, sudden cardiac death), and overall mortality were recorded. Multivariate Cox regression analysis was used to evaluate predictors of endpoints. Patients with and without radial artery grafts were similar with respect to preoperative risk factors. Recurrent angina developed in 29 patients, congestive heart failure in 5, and myocardial infarction in 9. Coronary arteriography was performed in 27 patients, and 23 underwent re-intervention. Radial artery graft was an independent predictor of increased symptom recurrence and adverse cardiac events. Patients with radial artery grafts also had a tendency towards more angina recurrence, coronary re-intervention, and sudden cardiac death.

Effects of pulsatile and nonpulsatile perfusion on vital organ recovery in pediatric heart surgery: a pilot clinical study.

The use of pulsatile flow during cardiopulmonary bypass (CPB) with regard to improved patient outcomes is controversial. We evaluated pulsatile perfusion in pediatric patients undergoing CPB in a clinical setting. Fifty consecutive pediatric patients undergoing open heart surgery for repair of congenital heart disease were prospectively entered into the study and randomly assigned to either the pulsatile perfusion group (group P, n = 25) or the nonpulsatile perfusion group (group NP, n = 25). Study parameters included intubation time, duration of intensive care unit (ICU) stay and hospital stay, need for inotropic support, preoperative and postoperative enzymes, creatinine, C-reactive protein, blood count, mean urine output, and total drainage. Group P, compared with group NP, had significantly less inotropic support (number of agents, 1.48 +/- 1.05 versus 2.44 +/- 1.03, p = 0.0015; dopamine, 6.48 +/- 3.27 versus 10.3 +/- 4.8 microg/kg per minute, p = 0.0023; dobutamine, 3.12 +/- 6.55 versus 8.03 +/- 9.1 microg/kg per minute, p = 0.034), shorter intubation period (20.36 +/- 17.02 versus 35.44 +/- 30.72 hours, p = 0.038), and shorter duration of ICU stay (2.16 +/- 1.07 versus 4.32 +/- 4.21 days, p = 0.028) and hospital stay (7.64 +/- 2.48 versus 11.84 +/- 6.82 days, p = 0.007). There were no significant differences in creatinine, enzyme levels, or drainage amounts between the two groups. Higher urine output during CPB (553.6 +/- 150.89 versus 465.8 +/- 151.23 ml/d, p = 0.045) and during the ICU period (658.8 +/- 210.99 versus 528,2 +/- 224.71 ml/d, p = 0.039) was observed in group P compared with group NP. We concluded that the use of pulsatile flow resulted in improved patient outcome in preserving cardiac function and maintaining better renal and pulmonic function (shorter intubation period) in the early postbypass period.

Previous percutaneous coronary intervention may increase symptom recurrence and adverse cardiac events following surgical revascularization.

OBJECTIVE: The number of percutaneous coronary interventions (PCI) is increasing. There is limited outcome data on patients with a history of PCI and subsequently required surgical revascularization. METHODS: Overall 611 patients who survived 30 days after coronary artery bypass graft surgery (CABG) between 2001 and 2005 were evaluated. Mean follow-up was 29.4 +/- 11.3 months and 45% were female. The effect of preoperative PCI as a risk factor for symptom recurrence and adverse cardiovascular events and mortality was determined. RESULTS: Preoperative PCI was an independent risk factor for symptom recurrence (p<0.0001), combined adverse cardiac events (p<0.0001) and slightly increased overall mortality (p<0.04). Comparison of patients with and without a prior PCI showed that former had significantly worse outcomes compared to the latter. Patients with history of at least one restenosis following a PCI developed significantly more adverse end points (p<0.0001). CONCLUSION: In this study, patients with previous PCI were more likely to develop symptom recurrence and adverse cardiovascular events following CABG. This difference was more pronounced in patients who had at least one recurrent stenosis after a PCI.

Postoperative clopidogrel improves mid-term outcome after off-pump coronary artery bypass graft surgery: a prospective study.

OBJECTIVE: Clopidogrel decreases recurrent ischemic events and improves intracoronary stent patency. There are scarce data on the effect of short-term and long-term clopidogrel on symptom recurrence and adverse cardiac events following off-pump coronary artery bypass graft surgery (OPCAB). METHODS: Postoperative antiplatelet medication use was prospectively evaluated in 591 OPCAB patients. Clopidogrel was administered for 30 days in 186 patients and 139 received long-term clopidogrel (mean 33.6+/-12.0 months) in addition to aspirin. Follow-up was 37.7+/-13.4 months. Symptom recurrence (angina and congestive heart failure), adverse cardiac events (myocardial infarction, coronary reintervention, and sudden cardiac death), and overall mortality were prospectively recorded. Multivariate Cox regression analysis was used to evaluate predictors of end points. RESULTS: There was no difference with respect to preoperative risk factors between patient groups. In the multivariate analysis, postoperative clopidogrel independently decreased symptom recurrence (p<0.0001, OR 0.3 [0.15-0.99]; 95% CI) and adverse cardiac events (p<0.0001, OR 0.2 [0.10-0.45]; 95% CI). Clopidogrel receivers had significantly lower angina recurrence, myocardial infarction, coronary reintervention, and sudden cardiac death during follow-up. There was no difference in the incidence of end points between short-term (30 days) and long-term receivers of the drug. There were 17 bleeding complications (4 major and 13 minor) in 15 patients during the follow-up period. Of the 15 patients, 6 were on clopidogrel in addition to aspirin (1.8%) while the remaining 9 were on aspirin (3.3%) only at the time of bleeding (p=0.8). CONCLUSIONS: Clopidogrel therapy was independently associated with decreased symptom recurrence and adverse cardiac events following OPCAB. Extending clopidogrel use beyond 30 days did not have a significant effect on defined end points.

Predictors of mid-term symptom recurrence, adverse cardiac events and mortality in 591 unselected off-pump coronary artery bypass graft patients.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) grafting is gaining popularity; however, decreased mid-term graft patency and increased coronary reintervention rates are reported. STUDY DESIGN: Five hundred and ninety-one consecutive unselected patients underwent OPCAB grafting from February 2000 to April 2004 (mean follow-up 38.54 +/- 0.54 months). One hundred and thirteen patients had < or =2 grafts, and four hundred and seventy-eight had > or =3 grafts. At least one radial artery graft was present in 398 patients, 328 received postoperative Clopidogrel, and 391 received postoperative statins. History of at least one percutaneous coronary intervention (PCI) was present in 192 patients. RESULTS: Twenty-nine patients developed recurrent angina, nine had myocardial infraction, and twenty underwent coronary reintervention. Five patients died of sudden cardiac death. Overall mortality was 4.9% during follow-up (29 patients). Postoperative Clopidogrel and statins as well as intraoperative shunt use significantly decreased symptom recurrence and adverse cardiac events. Diabetes, chronic obstructive pulmonary disease, prior history of PCI, and utilization of radial artery grafts were positive predictors of symptom recurrence and adverse cardiac events. Utilization of radial artery grafts, history of PCI as well as low preoperative ejection fraction increased mortality. Number of bypass grafts, type of conduit, grafted territory, hyperlipidemia, or prior coronary artery bypass graft surgery (CABG) did not influence symptom recurrence, adverse cardiac events or mortality. CONCLUSIONS: OPCAB grafting can be performed with low symptom recurrence, adverse cardiac events, and mortality rates. Modification of intra- and postoperative management strategies may improve outcomes.